ATTACHMENT
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Title I/LAP and Consolidated Program Review
Old Capitol Building
POBOX 47200
OLYMPIA WA 98504-7200
(360) 725-6100 TTY (360) 664-3631
PRESIDENTIAL SCHOLARS PROGRAM
2017–18
Individual School Form
PRINCIPAL OR PRIVATE SCHOOL DIRECTOR (PRINT)NAME OF HIGH SCHOOL / CEEB CODE
SCHOOL ADDRESS
CITY, STATE, ZIP
TELEPHONE / EMAIL
Each public and private Washington State high school may nominate one (1) female and one (1) male student.
Selected Student(s)
I certify that the above-named students meet the selection requirements and that the information on the Student Nomination Form is correct.
Principal's SignatureDate
Return by October 20, 2017, NO EXCEPTIONS, to:
Shailee Berry
Office of Superintendent of Public Instruction
Post Office Box 47200
Olympia, WA 98504-7200
This page must accompany the package of selected student’s application. Incomplete applications will not be considered.
This application consists of 4 pages including the Student Nomination Form and Individual School Form plus the student writing sample. All 4+ pages are required. The Office of Superintendent of Public Instruction will not assume responsibility for screening applications and notifying applicants of incomplete or missing information. Incomplete applications will be disqualified.
Office of Superintendent of Public Instruction
U.S. PRESIDENTIAL SCHOLARS PROGRAM2017–18
STUDENT NOMINATION FORM
A.BACKGROUND INFORMATION
STUDENT NAMELASTFIRSTMIDDLE / CEEB CODEMAILING ADDRESS (NUMBER AND STREET)
CITY, STATE, ZIP
B.INVOLVEMENT & SERVICE (School & Community)
B.1List the school activities in which this nominee has participated during grades 9–12.Please indicate by placing an "x" in theappropriate grade level(s).
Limit your response to the space provided in the table - one entry per line. Attach addendum in the same format if needed. Do not replace this format with a résumé. It will not be considered.
Student School Activities / Grade9 / 10 / 11 / 12
Example: Band / X / X / X
B.2List non-paid community service during grades 9–12.
Limit your response to the space provided in the table - one entry per line. Attach addendum in the same format if needed. Do not replace this format with a résumé. It will not be considered.
Community Activities / Hours per Week per GradeType of Service / 9 / 10 / 11 / 12
Example: Hospital Volunteer / 5 / 10 / 15 / 20
C.ACADEMIC ACHIEVEMENTS
List academic achievements, special recognition, awards, and honors received during grades 9–12.Please indicate by placing an "x" in the appropriate grade level(s). Only list commendations not previously listed. Limit your response to the space provided - one entry per line.
Achievements, Awards, Honors / Grade9 / 10 / 11 / 12
Example: National Merit Scholar / X
D.ACADEMIC STANDING
STUDENT’S NAME:
Please indicate below:
- Nominee's GPA (Weighted GPA’s are not accepted)
- Class rank out of (indicate by exact position: ex. 3 out of 150)
- SAT Scores: Critical Reading Math Writing
The nominee will graduate from:
School: Date:
E.Please include a writing sample from each nominee. Each student writing sample should be font size 11 or larger and limited to 1–2 pages. The student writing sample may be a previously completed classroom assignment or other writing sample. If handwritten, please check for legibility.
F.Please tell us about this student’s character and leadership. What about this student makes him or her stand out as having outstanding scholarship and promise of future success?
G.What challenges are you aware of that this student has overcome while still maintaining integrity and academic success?
Responses to sections F & G should be font size 11 or larger and limited to 1–2 pages combined maximum.
FORM SPI 1711 (Rev. 9/17)1